Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO"

Transcription

1 Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Certificate of Insurance or Evidence of Coverage (EOC). If there is a difference between this summary and the Certificate of Insurance or Evidence of Coverage (EOC), the Certificate of Insurance or Evidence of Coverage (EOC), will prevail. Covered Medical Benefits Overall Deductible See notes section to understand how your deductible works. Your plan may also have a separate Prescription Drug Deductible. See Prescription Drug Coverage section. s and s deductibles are combined. Satisfying one helps satisfy the other. Out-of-Pocket Limit When you meet your out-of-pocket limit, you will no longer have to pay cost-shares during the remainder of your benefit period. See notes section for additional information regarding your out of pocket maximum. $1,500 single / $3,000 family $3,000 single / $6,000 family $1,500 single / $3,000 family $11,500 single / $23,000 family Doctor Home and Office Services Preventive care/screening/immunization In-network preventive care is not subject to deductible, if your plan has a deductible. No charge 40% coinsurance Primary care visit to treat an injury or illness Specialist care visit Prenatal and Post-natal Care In network preventive pre natal and post natal services covered at 100%. Other practitioner visits: Retail health clinic On-line Visit Page 1 of 6

2 Covered Medical Benefits Chiropractor services Coverage for and combined is limited to 30 visit limit per benefit period. Deductible does not apply to In- Network providers. Acupuncture Coverage for and combined is limited to 20 visit limit per benefit period. Deductible does not apply to In- Network providers. Other services in an office: Allergy testing Chemo/radiation therapy Hemodialysis Prescription drugs For the drugs itself dispensed in the office thru infusion/injection Diagnostic Services Lab: X-ray: Office Freestanding Lab Outpatient Hospital Office Freestanding Radiology Center Outpatient Hospital Advanced diagnostic imaging (for example, MRI/PET/CAT scans): Office Freestanding Radiology Center Outpatient Hospital Emergency and Urgent Care Page 2 of 6

3 Covered Medical Benefits Emergency room facility services This is for the hospital/facility charge only. The ER physician charge may be separate. Copay waived if admitted. $150 copay per admission and then 20% coinsurance Covered as In- Network Emergency room doctor and other services 20% coinsurance Covered as In- Network Ambulance (air and ground) 20% coinsurance Covered as In- Network Urgent Care (office setting) Costs may vary by site of service. Deductible does not apply to providers. Outpatient Mental/Behavioral Health and Substance Abuse Doctor office visit Facility visit: Facility fees Outpatient Surgery Facility fees: Hospital Freestanding Surgical Center Doctor and other services Hospital Stay (all inpatient stays including maternity, mental / behavioral health, and substance abuse) Facility fees (for example, room & board) Co-pay $500 if you do not receive preauthorization. Apply to non-emergency admission. Doctor and other services Recovery & Rehabilitation Home health care Coverage for and combined is Page 3 of 6

4 Covered Medical Benefits limited to 100 day limit per benefit period. Rehabilitation services (for example, physical/speech/occupational therapy): Office Costs may vary by site of service. Outpatient hospital Habilitation services Cardiac rehabilitation Office Outpatient hospital Skilled nursing care (in a facility) Coverage for and combined is limited to 100 day limit per benefit period. Hospice No charge 40% coinsurance Durable Medical Equipment 50% coinsurance 50% coinsurance Prosthetic Devices Page 4 of 6

5 Notes: This Summary of Benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this Summary of Benefits. This Summary of Benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). In addition to the benefits described in this summary, coverage may include additional benefits, depending upon the member's home state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more generous benefits be provided to their residents, even if the master policy was not issued in their state. If the member's state has such requirements, we will adjust the benefits to meet the requirements. The family deductible and out-of-pocket maximum are embedded meaning the cost shares of one family member will be applied to the individual deductible and individual out-of-pocket maximum; in addition, amounts for all family members apply to the family deductible and family out-of-pocket maximum. No one member will pay more than the individual deductible and individual out-of-pocket maximum. All medical services subject to a coinsurance are also subject to the annual medical deductible. Annual Out-of-Pocket Maximums includes deductible, copays, coinsurance and prescription drug. In network and out of network out of pocket maximum are exclusive of each other. For plans with an office visit copay, the copay applies to the actual office visit and additional cost shares may apply for any other service performed in the office (i.e., X-ray, lab, surgery), after any applicable deductible. Preventive Care Services includes physical exam, preventive screenings (including screenings for cancer, HPV, diabetes, cholesterol, blood pressure, hearing and vision, immunization, health education, intervention services, HIV testing) and additional preventive care for women provided for in the guidance supported by Health Resources and Service Administration. For Medical Emergency care rendered by a Non-Participating or Non-Contracting Hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. If your plan includes an emergency room facility copay and you are directly admitted to a hospital, your emergency room facility copay is waived. If your plan includes out of network benefit and you use a non-network provider, you are responsible for any difference between the covered expense and the actual non-participating providers charge. Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan. Certain types of physicians may not be represented in the PPO network in the state where the member receives services. If such physician is not available in the service area, the member's copay is the same as for PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays, deductibles and charges which exceed covered expense. Additional visits maybe authorized if medically necessary. Pre-service review must be obtained prior to receiving the additional services. Page 5 of 6

6 If your plan includes out of network benefits, all services with calendar/plan year limits are combined both in and out of network. Transplants covered only when performed at Centers of Medical Excellence or Blue Distinction Centers. Bariatric Surgery covered only when performed at Blue Distinction Center for Specialty Care for Bariatric Surgery. Skilled Nursing Facility day limit does not apply to mental health and substance abuse. Respite Care limited to 5 visits per lifetime. Freestanding Lab and Radiology Center is defined as services received in a non-hospital based facility. Coordination of Benefits: The benefits of this plan may be reduced if the member has any other group health or dental coverage so that the services received from all group coverage do not exceed 100% of the covered expense When using non-network pharmacy; members are responsible for in-network pharmacy copay plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount. Members will pay upfront and submit a claim form. Preferred Generic Program: If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost of that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply. Supply limits for certain drugs may be different, go to Anthem website or call customer service. Certain drugs require pre-authorization approval to obtain coverage. For additional information on limitations and exclusions and other disclosure items that apply to this plan, go to For additional information on this plan, please visit sbc.anthem.com to obtain a Summary of Benefit Coverage. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) or visit us at CA/L/F/PPO/LP2069/LR2097/01-16 Page 6 of 6

Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 (RX $15/$40/$60/30%) Your Network: Prudent Buyer PPO

Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 (RX $15/$40/$60/30%) Your Network: Prudent Buyer PPO Anthem Blue Cross Life and Health Insurance Company Your Plan: Solution PPO 1500/15/20 (RX $15/$40/$60/30%) Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed

More information

Anthem Blue Cross Your Plan: Classic PPO 500/20/20 (RX $10/$30/$50/30%) Your Network: Prudent Buyer PPO

Anthem Blue Cross Your Plan: Classic PPO 500/20/20 (RX $10/$30/$50/30%) Your Network: Prudent Buyer PPO Anthem Blue Cross Your Plan: Classic PPO 500/20/20 (RX $10/$30/$50/30%) Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection

More information

Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO

Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO Your Plan: Value HMO 25/40/20% (RX $10/$30/$45/30%) Your Network: Select Plus HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary

More information

Your Plan: Premier HMO 20/200A/100 OP Your Network: California Care HMO

Your Plan: Premier HMO 20/200A/100 OP Your Network: California Care HMO Your Plan: Premier HMO 20/200A/100 OP Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect

More information

Anthem Blue Cross Your Plan: Custom Lumenos HSA /40 Embedded (LHSA291) -Actives Your Network: Prudent Buyer PPO

Anthem Blue Cross Your Plan: Custom Lumenos HSA /40 Embedded (LHSA291) -Actives Your Network: Prudent Buyer PPO Anthem Blue Cross Your Plan: Custom Lumenos HSA 2600 20/40 Embedded (LHSA291) -Actives Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with

More information

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

Your Plan: Anthem Gold PPO 500/20%/4500 Your Network: Prudent Buyer PPO

Your Plan: Anthem Gold PPO 500/20%/4500 Your Network: Prudent Buyer PPO Your Plan: Anthem Gold PPO 500/20%/4500 Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect

More information

Your Plan: Anthem Gold HMO 35/25%/6600 Your Network: California Care HMO

Your Plan: Anthem Gold HMO 35/25%/6600 Your Network: California Care HMO Your Plan: Anthem Gold HMO 35/25%/6600 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not

More information

Your Plan: Anthem Gold HMO 500/20%/5000 Your Network: California Care HMO

Your Plan: Anthem Gold HMO 500/20%/5000 Your Network: California Care HMO Your Plan: Anthem Gold HMO 500/20%/5000 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not

More information

Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60)

Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60) Anthem Blue Cross Life and Health Insurance Company University of California San Francisco Custom Premier PPO 200/20 (200/20/80/60) Summary of Benefits and Coverage: What this Plan Covers & What it Costs

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Anthem Blue Cross Stanislaus County: Custom EPO Coverage Period: 01/01/2015-12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type:

More information

Why this Matters: Even though you pay these expenses, they don t count toward the outof-pocket limit.

Why this Matters: Even though you pay these expenses, they don t count toward the outof-pocket limit. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/sisc or by calling 1-855-333-5730. Important

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Summary Plan Description (SPD) or Plan Document at www.pebtf.org or by calling 1-800-522-7279.

More information

Boston College Student Blue PPO Plan Coverage Period: 2015-2016

Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Boston College Student Blue PPO Plan Coverage Period: 2015-2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: PPO This is only a

More information

Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Coverage Period: 01/01/2015-12/31/2015

Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Coverage Period: 01/01/2015-12/31/2015 Anthem Blue Cross Blue Shield St. Charles School District Blue Access & Blue Access Choice PPO Base Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem BlueCross Premier HMO 20 / $10/$25/$45/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage For: Individual/Family Plan Type:

More information

ADVANCED SCIENCE BASIC HEALTH CARE PLAN

ADVANCED SCIENCE BASIC HEALTH CARE PLAN This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.loomisco.com or by calling 1-800-346-1223. Important

More information

Important Questions Answers Why this Matters: For PPO Providers. $150 Individual; maximum of two separate deductibles/ family. For Non-PPO Providers

Important Questions Answers Why this Matters: For PPO Providers. $150 Individual; maximum of two separate deductibles/ family. For Non-PPO Providers This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca or by calling 1-855-333-5730. Important

More information

Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier PPO 400/20%/20%

Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier PPO 400/20%/20% Anthem Blue Cross Life and Health Insurance Company University of Southern California Custom Premier 400/20%/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:

More information

University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Coverage Period: 01/01/2015-12/31/2015

University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Coverage Period: 01/01/2015-12/31/2015 University of Southern Indiana: Buy-Up Plan Blue Access (PPO) Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual/Family

More information

Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015

Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Blue Care Elect Preferred 90 Copay Coverage Period: on or after 09/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Only Plan Type: PPO This is only

More information

Administered by Capital BlueCross 1

Administered by Capital BlueCross 1 Administered by Capital BlueCross 1 PPO HRA Plan/Rx Plan This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at

More information

Massachusetts. The HPHC Insurance Company Best Buy Tiered Copayment ChoiceNet PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts

Massachusetts. The HPHC Insurance Company Best Buy Tiered Copayment ChoiceNet PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Massachusetts The HPHC Insurance Company Best Buy Tiered Copayment ChoiceNet PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 07/01/2015 06/30/2016 Coverage for: Individual

More information

Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014

Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014 Blue Care Elect Preferred Amherst College Coverage Period: on or after 07/01/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type:

More information

Even though you pay these expenses, they don t count toward the out-ofpocket limit.

Even though you pay these expenses, they don t count toward the out-ofpocket limit. Commonwealth of Virginia: COVA Care Basic Coverage Period: 07/01/2014 06/30/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO This

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Gold 80 PPO Network Name: Exclusive Coverage Period: Beginning on or after 1/1/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan Type:

More information

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual

More information

$0 See the chart starting on page 2 for your costs for services this plan covers.

$0 See the chart starting on page 2 for your costs for services this plan covers. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/lausd or by calling 1-800-700-3739. Important

More information

You can see the specialist you choose without permission from this plan.

You can see the specialist you choose without permission from this plan. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cvtrust.org or by calling 1-800-288-9870. Important Questions

More information

UMC Health Plan Operations Coverage Period: 01/01/2013-12/31/2013

UMC Health Plan Operations Coverage Period: 01/01/2013-12/31/2013 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthplanoperations@umchealthsystem.com or by calling

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem BlueCross BlueShield Blue Access PPO Option D58 / Rx Option 8 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 12/01/2013-11/30/2014 Coverage For: Individual/Family

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: Anthem Blue Cross Life and Health Insurance Company Unify: PPO Coverage Period: 01/01/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family

More information

HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015

HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 HMO Blue Basic Coinsurance Coverage Period: on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual and Family Plan Type: HMO This is only

More information

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts HPHC Insurance Company The Harvard Pilgrim Tiered Copayment PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 6/1/2013 5/31/2014 Coverage for: Individual

More information

University of California Student Health Insurance Plan (UC SHIP) Arthur Ashe Student Health & Wellness Center (The Ashe Center)

University of California Student Health Insurance Plan (UC SHIP) Arthur Ashe Student Health & Wellness Center (The Ashe Center) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.pebcinfo.com or by calling 214-653-6161. Important Questions Answers

More information

Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO

Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO Massachusetts The HPHC Insurance Company PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO This

More information

Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016

Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Blue Care Elect Saver with Coinsurance Northeastern University HDHP Coverage Period: on or after 01/01/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual

More information

LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

LGC HealthTrust: MT Blue 5-RX10/20/45 Coverage Period: 07/01/2013 06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com or by calling 1-800-870-3057. Important Questions

More information

Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO

Massachusetts. Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO Massachusetts The HPHC Insurance Company PPO Summary of Benefits and Coverage: WhatthisPlanCovers&WhatitCosts Coverage Period: 01/01/2015 12/31/2015 Coverage for: Individual + Family Plan Type: PPO This

More information

FELRA & UFCW Health Fund: Plan XX Summary of Benefits and Coverage: What this Plan Covers & What it Costs

FELRA & UFCW Health Fund: Plan XX Summary of Benefits and Coverage: What this Plan Covers & What it Costs FELRA & UFCW Health Fund: Plan XX Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual + Family Plan Type: PPO This is

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.arml.org\benefit_programs.html or by calling 1-501-978-6137.

More information

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at http://knowyourbenefits.dfa.ms.gov or by calling 1-866-586-2781.

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

What is the overall deductible?

What is the overall deductible? Regence BlueCross BlueShield of Oregon: Innova Coverage Period: 10/01/2013-09/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family

More information

Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015

Gundersen Health Plan: MN NJ Silver $2000-0% Coverage Period: 01/01/2015-12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gundersenhealthplan.org or by calling 1-800-897-1923.

More information

You can see the specialist you choose without permission from this plan.

You can see the specialist you choose without permission from this plan. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions

More information

(HSA) 1500/3000 10/30 (LHSA497)

(HSA) 1500/3000 10/30 (LHSA497) Lumenos Health Savings Account (HSA) 1500/3000 10/30 (LHSA497) 1/1/2016 This Summary of Benefits is a brief overview of your plan's benefits only. The benefits listed are for both in state and out of state

More information

Important Questions. What is the overall deductible?

Important Questions. What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cnichs.com or http://secure.healthx.com/cnic_new.aspx

More information

Massachusetts. Coverage Period: 1/1/2015 12/31/2015

Massachusetts. Coverage Period: 1/1/2015 12/31/2015 Massachusetts The Harvard Pilgrim Hospital Prefer Best Buy Tiered Copayment HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 1/1/2015 12/31/2015 Coverage for:

More information

Massachusetts. Coverage Period: 07/01/2014 06/30/2015 Coverage for: Individual + Family Plan Type: HMO

Massachusetts. Coverage Period: 07/01/2014 06/30/2015 Coverage for: Individual + Family Plan Type: HMO Massachusetts Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO-WSHG Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period:

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? : VIVA HEALTH Access Plan Coverage Period: 01/01/2015 12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document

More information

University of California Student Health Insurance Plan (UC SHIP) Student Health Center & Pharmacy (SHC) at UC Irvine (Graduate Students)

University of California Student Health Insurance Plan (UC SHIP) Student Health Center & Pharmacy (SHC) at UC Irvine (Graduate Students) This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet at www.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

Personal Blue PPO QHDHP $5,000/$10,000

Personal Blue PPO QHDHP $5,000/$10,000 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-800-962-2242. Important

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://eoc.anthem.com/eocdps/aso or by calling 1-888-650-4047.

More information

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan

This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.kaiserpermanente.org or by calling 1-800-464-4000. Important

More information

Summary of Benefits and Coverage What this Plan Covers & What it Costs

Summary of Benefits and Coverage What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the plan document at www.mpiphp.org or by calling 1-855-275-4674. Important Questions Answers

More information

Not applicable because there s no out-of-pocket limit on your expenses. You can see the specialist you choose without permission from this plan.

Not applicable because there s no out-of-pocket limit on your expenses. You can see the specialist you choose without permission from this plan. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.njcf.org or by calling 1-800-624-3096. Important Questions

More information

Nationwide Life Insurance Co.: Birmingham-Southern College Coverage Period: 8/25/13-8/24/14

Nationwide Life Insurance Co.: Birmingham-Southern College Coverage Period: 8/25/13-8/24/14 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important

More information

Important Questions Answers Why this Matters: Network: $500 Individual / $1,500 Family;

Important Questions Answers Why this Matters: Network: $500 Individual / $1,500 Family; This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.healthscopebenefits.com or by calling 1-866-208-4281.

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.thehealthplan.com or by calling 1-800-504-0443. Important

More information

Coverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters:

Coverage for: Individual, Family Plan Type: PPO. Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.bbsionline.com or by calling 1-866-927-2200. Important

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cfhp.com or by calling 1-800-434-2347. Important Questions

More information

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436. Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.

More information

What is the overall deductible?

What is the overall deductible? Regence BlueCross BlueShield of Oregon: HSA 2.0 Coverage Period: 07/01/2013-06/30/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual & Eligible Family

More information

Coverage for: Individual Plan Type: PPO. Important Questions Answers Why this Matters:

Coverage for: Individual Plan Type: PPO. Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.chpstudent.com or by calling 1-800-633-7867. Important

More information

State Health Plan: Savings Plan Coverage Period: 01/01/2015-12/31/2015

State Health Plan: Savings Plan Coverage Period: 01/01/2015-12/31/2015 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.eip.sc.gov or by calling 1-888-260-9430. Important Questions

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.boonchapman.com or by calling 1-800-252-9653. Important

More information

Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses?

Yes, $100 individual/$300 family for speech therapy. There are no other specific deductibles. Is there an out of pocket limit on my expenses? Yale Health Plan: Faculty, Managerial & Professional, Post-doctoral Associates and Fellows Coverage Period: 1/1/2015 12/31/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage

More information

Coverage for: Group Plan Type: HMO. Important Questions Answers Why this Matters: What is the overall deductible?

Coverage for: Group Plan Type: HMO. Important Questions Answers Why this Matters: What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at sutterhealthplus.org or by calling 1-855-315-5800. Important

More information

GHI-COMPREHENSIVE BENEFITS PLAN/EMPIRE BLUECROSS BLUESHIELD HOSPITAL PLAN (GHI-CBP)

GHI-COMPREHENSIVE BENEFITS PLAN/EMPIRE BLUECROSS BLUESHIELD HOSPITAL PLAN (GHI-CBP) GHI-COMPREHENSIVE BENEFITS PLAN/EMPIRE BLUECROSS BLUESHIELD HOSPITAL PLAN (GHI-CBP) GHI-CBP option consists of two components: GHI, an EmblemHealth company, offering benefits for medical/physician services,

More information

Individual Plan: Silver 1 93-95 Coverage Period: 01/01/2014-12/31/2014

Individual Plan: Silver 1 93-95 Coverage Period: 01/01/2014-12/31/2014 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cchpsc.org or by calling 1-800-580-8736 or TTY 1-800-545-8279

More information

Alternate PPO/Alternate Rx

Alternate PPO/Alternate Rx This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-866-802-4761. Important

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More information

Coverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. Important Questions Answers Why this Matters:

Coverage Period: 8/1/2013-7/31/2014 Coverage for: Insured Student+Dependent Plan Type: PPO. Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.gallagherkoster.com/colgate or by calling 1 877-371-9621.

More information

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No.

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More information

Health Alliance Plan. Coverage Period: 01/01/2015-12/31/2015. document at www.hap.org or by calling 1-800-422-4641.

Health Alliance Plan. Coverage Period: 01/01/2015-12/31/2015. document at www.hap.org or by calling 1-800-422-4641. Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage for: Individual+Family Plan Type: HMO This is only a summary.

More information

Healthy Benefits PPO 6000.0 - Zero Cost Sharing Plan Variation Coverage Period: Beginning on or after 1/1/2014 Summary of Benefits and Coverage:

Healthy Benefits PPO 6000.0 - Zero Cost Sharing Plan Variation Coverage Period: Beginning on or after 1/1/2014 Summary of Benefits and Coverage: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at capbluecross.com or by calling 1-800-730-7219. Important

More information

Important Questions Answers Why this Matters: Preferred Provider: $1,000 per Person/2,000 Family

Important Questions Answers Why this Matters: Preferred Provider: $1,000 per Person/2,000 Family This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.wpsic.com or by calling 1-888-915-4001. Important Questions

More information

Pacific Union College: Base Buy-Up Plan Option Coverage Period: 07/01/2015 06/30/2016

Pacific Union College: Base Buy-Up Plan Option Coverage Period: 07/01/2015 06/30/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.deltahealthsystems.com or by calling the Benefits Help

More information

Oregon s Health CO-OP Oregon Standard Silver Plan Broad Network: Coverage Period: 1/1/2015-12/31/2015. Important Questions Answers Why this Matters:

Oregon s Health CO-OP Oregon Standard Silver Plan Broad Network: Coverage Period: 1/1/2015-12/31/2015. Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://www.ohcoop.org/families-individuals/our-plans/plan-documents

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.

More information

Anthem Blue Cross: 100-C $20; Rx 7-25 Coverage Period: 10/01/2015-09/30/2016

Anthem Blue Cross: 100-C $20; Rx 7-25 Coverage Period: 10/01/2015-09/30/2016 This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/ca/sisc or by calling 1-855-333-5730. Important

More information

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.cirstudenthealth.com/udmercy or by calling 1-800-322-9901.

More information

Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs

Bowling Green State University : Plan B Summary of Benefits and Coverage: What This Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at MedMutual.com/SBC or by calling 800.540.2583. Important Questions

More information

RIT Blue Point2 POS B Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs

RIT Blue Point2 POS B Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.excellusbcbs.com or by calling 1-800-499-1275/V;

More information

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16

S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 S c h o o l s I n s u r a n c e G r o u p Health Net Plan Comparison Fiscal Year 7/1/15-6/30/16 This information sheet is for reference only. Please refer to Evidence of Coverage requirements, limitations

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: PPO Student/Affiliate Plan MIT Student/Affiliate Extended Insurance Plan Coverage Period: 2014-2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual, Couple,

More information

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Best Buy HSA PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Massachusetts. HPHC Insurance Company The Harvard Pilgrim Best Buy HSA PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts HPHC Insurance Company The Harvard Pilgrim Best Buy HSA PPO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014 12/31/2014 Coverage for: Individual

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: HealthKeepers Anthem HealthKeepers 20 POS / $10/$20/$35/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2015-12/31/2015 Coverage For: Individual/Family

More information

2015 Medical Plan Summary

2015 Medical Plan Summary 2015 Medical Plan Summary AVMED POS PLAN This Schedule of Benefits reflects the higher provider and prescription copayments for 2015. This is not a contract, it s a summary of the plan highlights and is

More information

Massachusetts. Coverage Period: 7/1/2013 6/30/2014 Coverage for: Individual + Family Plan Type: HMO

Massachusetts. Coverage Period: 7/1/2013 6/30/2014 Coverage for: Individual + Family Plan Type: HMO Harvard Pilgrim Health Care, Inc. The Harvard Pilgrim Best Buy Tiered Copayment ChoiceNet HMO Summary of Benefits and Coverage: What this Plan Covers & What it Costs Massachusetts Coverage Period: 7/1/2013

More information

StudentBlue University of Nebraska

StudentBlue University of Nebraska Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family Plan Type: PPO What is the overall deductible? This is only a summary. If you want more details about

More information

What is the overall deductible? Are there other deductibles for specific services?

What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your medical/vision coverage and costs, you can get the complete terms in the policy or plan document at www.mycigna.com, by calling 1-800-Cigna24,

More information

Are there other deductibles for specific services?

Are there other deductibles for specific services? Blue Shield of CA Life & Health Active Choice Plan 750 Coverage Period: 04/01/2015-03/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family Plan

More information

In-network: $5,000 per insured/ $10,000 per family per calendar year. Out-of-network: $10,000 per insured / $20,000

In-network: $5,000 per insured/ $10,000 per family per calendar year. Out-of-network: $10,000 per insured / $20,000 Regence BlueShield of Idaho: Coverage Period: Beginning on or after 01/01/2014 Regence Individual Direct Bronze HSA Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for:

More information

HealthyBlue PPO $1500 Coverage Period: 01/01/2014-12/31/2014

HealthyBlue PPO $1500 Coverage Period: 01/01/2014-12/31/2014 HealthyBlue PPO $1500 Coverage Period: 01/01/2014-12/31/2014 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual Plan Type: PPO This is only a summary. If you

More information

-----------------None-------------------------------

-----------------None------------------------------- This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the Benefit Booklet twww.ucop.edu/ucship or by calling 1-866-940-8306. Important Questions

More information

$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific

$0 See the chart starting on page 2 for your costs for services this plan covers. Are there other deductibles for specific This is only a summary. If you want more detail about your medical coverage and costs, you can get the complete terms in the policy or plan document at www.teamsters-hma.com or by calling 1-866-331-5913.

More information